Metformin for prevention of hypertensive disorders of pregnancy in women with gestational diabetes or obesity: systematic review and meta-analysis of randomized trials

OBJECTIVE

Metformin has been reported to reduce the risk of pre-eclampsia. It is also known to influence soluble fms-like tyrosine kinase-1 level, which correlates significantly with the gestational age at onset and severity of pre-eclampsia. The main aim of this systematic review and meta-analysis of randomized trials was to determine whether metformin use is associated with the incidence of hypertensive disorders of pregnancy (HDP).

METHODS

MEDLINE (1947 to September 2017), Scopus (1970 to September 2017) and the Cochrane Library (inception to September 2017) were searched for relevant citations in the English language. Only randomized controlled trials on metformin use, reporting the incidence of pre-eclampsia or pregnancy-induced hypertension, were included. Studies on populations with a high probability of metformin use prior to randomization (those with type II diabetes or polycystic ovary syndrome) were excluded. Random-effects models with the Mantel-Haenszel method were used for subgroup analyses. Bayesian random-effects meta-regression was used to summarize the evidence.

RESULTS

In total, 3337 citations matched the search criteria. After evaluating 2536 abstracts and performing full-text review of 52 studies, 15 were included in the review. In women with gestational diabetes, metformin use was associated with a reduced risk of pregnancy-induced hypertension when compared with insulin (relative risk (RR), 0.56; 95% CI, 0.37-0.85; I²  = 0%; 1260 women) and a non-significantly reduced risk of pre-eclampsia (RR, 0.83; 95% CI, 0.60-1.14; I²  = 0%; 1724 women). In obese women, when compared with placebo, metformin use was associated with a non-significant reduction in risk of pre-eclampsia (RR, 0.74; 95% CI, 0.09-6.28; I²  = 86%; 840 women). In women with gestational diabetes, metformin use was also associated with a non-significant reduction in risk of any HDP (RR, 0.71; 95% CI, 0.41-1.25; I²  = 0%; 556 women) when compared with glyburide. When studies were combined using Bayesian random-effects meta-regression, with treatment type as a covariate, the posterior probabilities of metformin having a beneficial effect on the prevention of pre-eclampsia, pregnancy-induced hypertension and any HDP were 92.7%, 92.8% and 99.2%, respectively, when compared with any other treatment or placebo.

CONCLUSIONS

There is a high probability that metformin use is associated with reduced HDP incidence when compared with other treatments or placebo. The small number of studies included in the analysis, the low quality of evidence and the clinical heterogeneity preclude generalization of these results to broader populations. Given the clinical importance of this topic and the magnitude of effect observed in this meta-analysis, further prospective trials are urgently needed. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Structure and organisation of the pyrimidine biosynthesis pathway genes in Lactobacillus plantarum: a PCR strategy for sequencing without cloning

This report describes the sequence and structural organisation of the pyrimidine biosynthesis pathway genes of Lactobacillus plantarum CCM 1904. It also describes an in vitro technique based on PCR for sequencing without cloning. This new technique was developed because it was impossible to clone certain parts of the L. plantarum genomic DNA in the Escherichia coli host. L. plantarum pyr genes are organised as a 9.8-kb operon with the following order: pyrR, pyrB, pyrC, pyrAA, pyrAB, pyrD, pyrF and pyrE. There are two major differences from the pyrimidine operons of Bacillus subtilis (Quinn et al., J. Bacteriol. 266 (1991) 9113-9127; Turner et al., J. Bacteriol, 176 (1994) 3708-3722) and Bacillus caldolyticus (Ghim et al., Microbiology 140 (1994) 479-491): the absence of pyrP encoding for uracil permease, and the absence of an open reading frame named orf2, whose function is unknown. Two mutually exclusive stem-loop structures were predicted at the 5'-end of L. plantarum pyr mRNA; this operon could be regulated by transcriptional attenuation under the control of PyrR. Complementation of E. coli pyrD, pyrF and pyrE mutants was obtained with a L. plantarum genomic DNA library. Alignment of the L. plantarum Pyr proteins with other known procaryotic Pyr proteins indicates that they display highly conserved regions in Gram-positive and Gram-negative bacteria.

Prevalence and Incidence of Non-neutralizing Antibodies in Congenital Hemophilia A- A Systematic Review and Meta-Analysis

Objectives: In hemophilia A the presence of non-neutralizing antibodies (NNAs) against Factor VIII (FVIII) may predict the development of neutralizing antibodies (inhibitors) and accelerate the clearance of administrated FVIII concentrates. This systematic review aimed to assess: (1) the prevalence and incidence of NNAs in patients with congenital hemophilia without inhibitors and (2) the association between NNAs and patient and treatment characteristics.

Methods: We conducted a search in MEDLINE, Embase, Web of Science and the Cochrane database. We included cross-sectional and longitudinal studies reporting on NNAs in patients with hemophilia A and B, who were inhibitor-negative at the start of the observation period. Data were extracted on: hemophilia type and severity, patient and treatment characteristics, NNA prevalence and incidence, NNA assays and inhibitor development. Two independent reviewers performed study selection, data extraction and risk of bias assessment, using adapted criteria of the Joanna Briggs Institute. Studies were classified as high-quality when ≥5/9 criteria were met. NNA assays were classified as high-quality when both quality criteria were met: (1) use of positive controls and (2) competition with FVIII to establish FVIII-specificity. We reported NNA prevalence and incidence for each study. The pooled NNA prevalence was assessed for well-designed studies in previously treated patients, employing high-quality NNA assays.

Results: We included data from 2,723 inhibitor-negative patients with hemophilia A, derived from 28 studies. Most studies were cross-sectional (19/28) and none reported on NNAs in hemophilia B. Study design was of high quality in 16/28 studies and the NNA assay quality was high in 9/28 studies. Various NNA assays were used, predominantly ELISA (18/28) with different cut-off values. We found a large variety in NNA prevalence (Range, 0–100%). The pooled NNA prevalence in high-quality studies was 25% (95% CI, 16–38%). The incidence of new NNA development was reported in one study (0.01 NNA per person-exposure day).

Conclusion: This systematic review identified studies that were heterogeneous in study design, patient population and NNA assay type, with NNA prevalence ranging from 0 to 100% in inhibitor-negative patients with hemophilia A. The pooled NNA prevalence was 25% in high-quality studies including only previously treated patients and performing high-quality NNA assays.

The effect of angiotensin II receptor antagonists on kidney function in two-kidney, two-clip Goldblatt hypertensive rats

The effect of blockade of the renin-angiotensin system on kidney function using non-peptide angiotensin AT1 receptor antagonists was investigated in renovascular hypertensive rats. An angiotensin converting enzyme inhibitor, captopril and two angiotensin AT1 receptor antagonists, losartan and GR138950 (1-([3-bromo-2[2-[[(trifluoro-methyl)sulphonyl]amino]phenyl]-5 benzofuranyl]methyl)-4-cyclopropyl-2-ethyl-1H-imidazole-5-carboxamide) were administered in Na+-deplete two-kidney, two-clip Goldblatt hypertensive rats over a 3-day period. Captopril, losartan (30 mg/kg body weight) and GR138950 (5 mg/kg body weight) significantly (P < 0.001) lowered the systolic blood pressure in the hypertensive rats from 290 +/- 5, 252 +/- 9 and 238 +/- 13 mmHg to 152 +/- 17, 148 +/- 9 and 123 +/- 6 mmHg, respectively. The magnitude of reduction in blood pressure in these three groups of rats was similar and occurred with comparable marked increases in plasma levels of urea and creatinine indicative of acute renal failure. These findings demonstrate an important role for angiotensin II in the maintenance of renal function during blood pressure reduction in renovascular hypertensive states during restriction of dietary Na+ intake.

Failure of an Innovative Low-Cost, Noninvasive Thermotherapy Device for Treating Cutaneous Leishmaniasis Caused by Leishmania tropica in Pakistan

Cutaneous leishmaniasis (CL), a neglected parasitic skin disease, is endemic in Pakistan, where Leishmania tropica and Leishmania major are the causative protozoan species. Standard treatment with antimonial injections is long, painful, and costly; has toxic side effects; and is not always available in public hospitals. Small pilot studies have previously evaluated a low-cost and noninvasive hand-held exothermic crystallization thermotherapy for cutaneous leishmaniasis (HECT-CL) device. We aimed to further establish the effectiveness, safety, and feasibility of HECT-CL in L. tropica. In a prospective observational study, patients with parasitological confirmation of CL were treated using the HECT-CL heat pack for 3 minutes with an initial temperature of 52–53°C for 7 consecutive days. Dried blood spot samples were taken for species identification by polymerase chain reaction (PCR). Effectiveness was assessed by using medical photographs and measurements of the lesion size at baseline and subsequent follow-up visits, for up to 180 days. We intended to enroll 317 patients. The HECT-CL treatment was easy to apply and well tolerated. Species identification demonstrated the presence of L. tropica. Interim analysis of 56 patients showed a failure rate of 91% at follow-up (median 45 days after treatment, interquartile range 30–60 days). Enrollment of patients was prematurely suspended because of futility. This study showed a high failure rate for HECT-CL thermotherapy in this setting. Leishmania tropica is known to be less sensitive to antileishmanial drugs, more temperature-resistant, and spontaneous healing is slower than that in L. major. More research is needed to identify low-cost, effective, and more patient-friendly treatment for L. tropica.

In Vitro and in Vivo Hemocompatibility Evaluation of Graphite Coated Polyester Vascular Grafts

Attempts have been made in this study to prepare a homogeneous and stable coating of graphite on polyester vascular grafts (GPVG) using an electrophoresis method to evaluate thromboresistant and blood compatibility of GPVG in comparison to non-coated PVG and InterGard (collagen sealed PVG) as control.

Lactate dehydrogenase (LDH) activity measurement was carried out on all PVG types to evaluate platelet adhesion. To examine tissue reaction GPVG and non-coated sheets of knitted polyester fabric were implanted simultaneously in the dorsal flank of rats subcutaneously. The GPVG, non-coated and control were implanted in descending aorta as end-to-end or end-to-side implantation substitution in 25 sheep for 4–60 weeks.

Results showed that the graphite coating on polyester vascular grafts reduced the number of adherent platelets and prevent platelet activation and spreading on the surface in comparison with non-coated and control. Pathological investigation showed inflammatory reactions were totally resolved after 12 weeks and there was no difference in the tissue reaction between graphite coated, non-coated and control patches. All grafts remained patent and there was no significant difference in patency rate between these three types of PVG. We found that GPVG has no need for pre-clotting and it showed lower platelet aggregation, thinner capsule formation and lower calcification after 15 months. However, suturing of GPVG was more difficult in comparison with the other types.

Management of a giant retroperitoneal leiomyoma: a case report

Background

Leiomyomas are benign tumors observed mainly in adult women. The retroperitoneum is a rare location for leiomyomas; almost 100 cases have been reported. Because retroperitoneal leiomyomas are paucisymptomatic and the tumor size at diagnosis is relatively large, surgical management is challenging. Regular follow-up is required because recurrence and malignant sarcomatous transformation have been described in a few cases.

Case presentation

We report a case of a 52-year-old North African woman with a 22-cm retroperitoneal leiomyoma. A preoperative embolization was performed 2 days before surgery. The clinical, therapeutic, and evolutive aspects of this rare entity are discussed.

Conclusions

Despite its benignity, retroperitoneal leiomyoma is a challenging diagnostic, therapeutic, and evolutive condition. Surgeons must consider mainly the tumor’s vascularization. Regular follow-up is mandatory because malignant transformation cannot be excluded.

Importance of the renin-angiotensin system in the generation of kidney failure in renovascular hypertension

OBJECTIVES

To determine the possible relationship between the degree of dietary sodium intake and the development of renal failure during blockade of the renin-angiotensin system.

DESIGN

Antihypertensive doses of captopril, an angiotensin converting enzyme, and hydralazine, a non-specific vasodilator, were administered in sham-operated and two-kidney, two clip Goldblatt hypertensive rats subjected to various degrees of dietary sodium intake.

METHODS

The blood pressure, water intake, urine flow and sodium excretion of the animals were determined before and during a 3-day period of drug administration. Plasma concentrations of urea and creatinine were measured as indicators of renal function and glomerular filtration rate.

RESULTS

The blood pressure of the clipped rats was higher than that of sham-operated rats (241 +/- 5 versus 150 +/- 4 mmHg), regardless of their sodium intake. Captopril administration failed to lower blood pressures of sodium-replete hypertensive rats, but in hypertensive rats fed either a low- or a 'no'-sodium diet the blood pressure was reduced by 45 +/- 7 and 127 +/- 19 mmHg, respectively. Furthermore, hydralazine reduced blood pressure in hypertensive rats fed a 'no'-sodium diet by a similar degree, to 99 +/- 8 mmHg. Captopril, but not hydralazine, significantly increased plasma levels of urea and creatinine in hypertensive rats fed the 'no'-sodium diet.

CONCLUSION

These findings indicate that angiotensin II plays an important role in the maintenance of renal function during blood pressure reduction by angiotensin converting enzyme inhibition in volume-contracted renovascular hypertensive states.

Preparations based on minerals extracts of Calicotome villosa roots and bovine butyrate matter: Evaluation in vitro of their antifungal activity

OBJECTIVE

The use of preparations based on minerals extracts of Calicotome villosa and butter is born from the misuse of drugs without specific microbiological analyzes. Seventeen different preparations were performed. The antibacterial and antifungal activities were determined on five bacteria and two fungi strains respectively.

MATERIAL AND METHODS

C. villosa ashes are obtained by incineration of roots plant at 498°C for 4hours. They are analyzed to determine the shape of the particles and the mineral constituents by scanning electronic microscopy (SEM) and energy dispersive X-ray spectroscopy (EDX) techniques respectively. The effectiveness of preparations or tablets is measured in solid medium. It allows to measure the diameter of the inhibition zone for the antibacterial activity as well as the diameter of mycelia growth and the critical values (MIC, MFC, IC₅₀ and IC₉₀) for the antifungal activity. Finally, the results are compared to the activity of a commercial positive control aiming to give value of the observed activity.

RESULTS

SEM observations reveal the presence of nanoparticles agglomerated with size of about 50nm. The EDX analyzes indicate the presence of Fe, Na, Al, Mg, Si, K, Ca, O₂ and C. Among all the results, the preparation (B_s+A) or (B_sd+A) can completely inhibit the growth of two fungal pathogens. The activity of the preparation is faced with the activity of the synthetic fungicide nystatin.

CONCLUSION

The efficacy of the preparation (B_s+A) or (B_sd+A) is higher than that of nystatin against Aspergillus sp. and Fusarium sp. The preparation could serve as natural antifungal for the pharmaceutical industry.

[Fasciola hepatica distomatosis in Maghreb. 2 new Algerian cases]

A bibliographic survey is made of the cases of fasciolasis in Maghreb, and it can be concluded that: The notion of "epidemy", or better, of simultaneous cases, brought to the diagnosis evocation, to explorations by I.D.R. and to early treatment, before the excretion of eggs. Due to drug-efficiency, the coprological proof of the disease was generally missing in the old "epidemies" of the Maghreb. Isolated cases, in contrast, where the fasciolasic etiology was not evocated, could follow natural evolution and the proof by egg or adult discovery was possible in more than half the cases. Progress in immunology of fasciolasis made possible the diagnosis of less than 10 nw cases in Tunisia and Marocco. The authors report 2 new cases from the Constantine region (Algeria). The repartition of the ascertained cases and the possible ones is shown on a map.

Fixed dose combination short course chemotherapy in the treatment of pulmonary tuberculosis

In this study two highly effective chemotherapeutic regimens of 6 and 8 months duration were studied and compared with the standard 12 month therapy under full supervision at the National TB Centre and St. Peter's TB Hospital in Addis Abeba. Patients with direct smear positive pulmonary tuberculosis were admitted to hospital during the initial phase of treatment for two months. At two months, sputum conversion rates, by direct smear and culture respectively, were 82% and 80% on Rifater, and 86 or 88% and 86% on the regimens containing separate preparations of isoniazid rifampicin and pyrazinamide, compared to 60% and 30% on the standard regimen. It was concluded that short course regimens of six or eight months with drugs either in combined form or separate preparations are more effective than the standard regimen.

Risks and seasonal pattern for mortality among hospitalized infants in a conflict-affected area of Pakistan, 2013-2016. A retrospective chart review

Background: In recent years, Médecins Sans Frontières has observed high mortality rates among hospitalized infants in Pakistan. We describe the clinical characteristics of the infants admitted between 2013 and 2016 in order to acquire a better understanding on the risk factors for mortality. 

Methods: We analyzed routinely collected medical data from infants (<7 months) admitted in Chaman and Dera Murad Jamali (DMJ) hospitals. The association between clinical characteristics and mortality was estimated using Poisson regression.

Results: Between 2013 and 2016, 5,214 children were admitted (male/female ratio: 1.60) and 1,178 (23%) died. Days since admission was associated with a higher risk of mortality and decreased with each extra day of admission after seven days. The first 48 hours of admission was strongly associated with a higher risk of mortality. A primary diagnosis of tetanus, necrotizing enterocolitis, prematurity, sepsis and hypoxic-ischemic encephalopathy were strongly associated with higher rates of mortality. We observed an annual peak in the mortality rate in September.

Conclusions: The first days of admission are critical for infant survival. Furthermore, the found male/female ratio was exceedingly higher than the national ratio of Pakistan. The observed seasonality in mortality rate by week has not been previously reported. It is fully recommended to do further in-depth research on male/female ratio differences and the reasons behind the annual peaks in mortality rate by week.

Advancements in Understanding the Hide-and-Seek Strategy of Hibernating Breast Cancer Cells and Their Implications in Oncology from a Broader Perspective: A Comprehensive Overview

Despite recent advancements in technology, breast cancer still poses a significant threat, often resulting in fatal consequences. While early detection and treatments have shown some promise, many breast cancer patients continue to struggle with the persistent fear of the disease returning. This fear is valid, as breast cancer cells can lay dormant for years before remerging, evading traditional treatments like a game of hide and seek. The biology of these dormant breast cancer cells presents a crucial yet poorly understood challenge in clinical settings. In this review, we aim to explore the mysterious world of dormant breast cancer cells and their significant impact on patient outcomes and prognosis. We shed light on the elusive role of the G9a enzyme and many other epigenetic factors in breast cancer recurrence, highlighting its potential as a target for eliminating dormant cancer cells and preventing disease relapse. Through this comprehensive review, we not only emphasise the urgency of unravelling the dynamics of dormant breast cancer cells to improve patient outcomes and advance personalised oncology but also provide a guide for fellow researchers. By clearly outlining the clinical and research gaps surrounding dormant breast cancer cells from a molecular perspective, we aim to inspire further exploration of this critical area, ultimately leading to improved patient care and treatment strategies.

[Pollen composition of the air in Annaba (north-eastern Algeria)]

The originality of the city of Annaba is that it is situated between two big ecological surroundings, to know, the Mediterranean sea to the north and the forest covering the massif of the Edough to the west. It incited us to determine to what point the vegetation of massif, influence it atmospheric pollen of the city of Annaba, notably in pollens allergisants. Of our survey, it comes out again that the region of Annaba is submitted to the influence of the massif of the Edough, because pollinic specter has reveled that nearly the half of pollens atmospheric identified belongs to the forest plants. The remainder of pollen belongs to humid, swampy, uncultivated zone species and of culture plants. In the end we can said that: the topography, the climatic conditions, and the speed of wind are factors determining the richness of the atmospheric in pollen.